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Providence Health Plans Enrollment Form

Tips for completing your application:

1. Please read everything carefully and answer all questions honestly. This document becomes part of your health insurance contract. Please make sure you have downloaded and completed the correct application.
   
   
2. Please complete all sections to the best of your ability. Please pay special attention to the health history Section.  By including the specific details to questions you answered "yes" to - the processing of your application will be expedited. Be sure to include:
   • The specific name and date of the diagnosis or condition and correct spelling.
   • The treatment(s) that were done, including the last time you visited the doctor for this condition and medications that were prescribed and medications that are currently being taken.
   • Final result refers to the status of the condition. If it has been treated and your doctor has not requested any follow-ups, please state so. If you are still seeing the doctor, please state so.
   • Complete name, address and phone number of the doctor.


3. Provide Certificate of Creditable Coverage (if available)
   Please refer to Credit for Prior Coverage Eligibility for more information. Please note, if you do not have your Certificate of Creditable Coverage at the time of application, please submit your application anyway. Credit for pre-existing condition waiting periods will be credited upon receipt of your Certificate of Creditable Coverage by Providence Health Plans of Oregon.
   
   
4. Do not include any payments with this application: The payment options are monthly bank draft or direct bill. You will be contacted on approval for payment and the payment options that are available to you
   
   
5. Final check list before mailing:
   • All sections completed?
   • Copy of Insurance Card or Certificate of Creditable Coverage
   • Signed and Dated
     
     
6. Send all Enrollment Materials to:
   CDA Insurance LLC
   PO Box 26540
   Eugene, OR 97402